Sample Child Assent for Children under Age 12
(To be read aloud to the child)
My name is [identify yourself to the child by name]. I work with parents and children but I am also a
student. Right now, I am trying to learn more about [provide a simple explanation of what the study is
about in language that is appropriate to both the child’s maturity and age].
If you agree, you will be asked to [describe what will take place using appropriate language from the
child’s point of view, including the time involved].
You may be helping us understand [describe topic] or [say what direct benefits are to child].
[If the study takes place in a school, children should know that:]
If you agree to help us, you should know that your teacher and classmates won’t know what you’ve
[e.g., said, drawn, chosen; whatever the child is being asked to do ]. You should also know that if you
decide to help us or if you decide to say “no,” your choice will not affect [ your grades, or whether
people like you, or an appropriate statement for the age group].
[If the study involves specific questions:]
There are no right or wrong answers.
Please talk this over with your parents before you decide if you want to be in my study or not. I will
also ask your parents to give their permission for you to be in this study, but even if your parents say
“yes,” you can still say “no” and decide not to be in the study.
If you don’t want to be in my study, you don’t have to be in it. Remember, being in the study is up to
you and no one will be upset if you don’t want to be in the study or if you decide to stop after we
begin, that’s okay, too. Also, remember that no one else, not even your parents, will know what you’ve
[e.g., said, drawn, chosen, written; whatever the child is being asked to do.]
You can ask any questions that you have about the study. If you have a question later that you didn’t
think of now, you can call me or ask [your parents, teacher, whoever the child may choose] to call me
at: [insert telephone number].
Would you like to [e.g., play a game, talk to me, draw a picture; whatever the activity is]?
[Child answers yes or no; only a definite yes may be taken as consent to participate.]